DIVERS’ MEDICAL QUESTIONNAIRE
To The Participant:
The purpose of this Medical Questionnaire is to find out if
you should be examined by a doctor before participating
in recreational scuba diving. A positive response to a
question does not necessarily disqualify you from diving.
A positive response means that there is a pre-existing
condition that may affect your safety while diving and you
must seek the advice of a physician prior to engaging in
dive activities.
___
___
___
Could you be pregnant, or are you attempting to
become pregnant?
Are you presently taking prescription medications?
(With the exception of birth control or anti-malarial).
Are you over 45 yrs of age and can answer YES to
one or more of the following?

Currently smoke a pipe, cigars or cigarettes

Have a high cholesterol level

Have a family history of heart attack or stroke

Are currently receiving medical care

High blood pressure

Diabetes mellitus, even if controlled by diet
alone.
Have you ever had or do you currently have …
___
___
Dysentery or dehydration requiring medical intervention?
___
Any dive accidents or decompression sickness?
___
Inability to perform moderate exercise (ex: walk 1.6
km/one mile within 12 mins)?
___
Head injury with loss of consciousness in the past five
years?
___
Recurrent back problems?
___
Back or spinal surgery?
___
Diabetes?
___
Back, arm or leg problems following surgery, injury or
fracture?
Asthma, or wheezing with breathing, or wheezing
___
with exercise?
___
Please answer the following questions on your past or
present medical history with a YES or NO. If you are not
sure, answer YES. If any of these items apply to you, we
must request that you consult with a physician prior to
participating in scuba diving.
High blood pressure or take medicine to control blood
pressure?
Frequent or severe attacks of hayfever or allergy?
Frequent colds, sinusitis or bronchitis?
___
Heart disease?
___
Pneumothorax (collapsed lung)?
___
Heart attack?
___
Other chest disease or chest surgery?
___
Angina, heart surgery or blood vessel surgery?
___
Behavioural
psychological
___
Sinus surgery?
problems (Panic attack, fear of closed or open
___
Ear disease or surgery, hearing loss or problems with
___
health,
mental
or
balance?
spaces)?
___
___
___
___
Recurrent ear problems?
medications to prevent them?
___
Bleeding or other blood disorders?
Recurring complicated migraine headaches or
___
Hernia?
take medications to prevent them?
___
Ulcers or ulcer surgery?
___
A colostomy or ileostomy?
___
Recreational drug use or treatment for, or alcoholism in
Epilepsy,
Blackouts
seizures,
or
fainting
convulsions
(full/partial
or
loss
take
of
consciousness)?
___
Frequent or severe suffering from motion sickness
the past five years?
(seasick, carsick, etc.)?
The information I have provided about my medical history is accurate to the best of
my knowledge. I agree to accept responsibility for omissions regarding my failure to
disclose any existing or past health condition.
____________________________________________
_________
Signature
Date
_________
____________________________________
Date
Signature of Parent or Guardian
(If Participant under 18 years of age)
AQUAVENTURE LIMITED
The Waters Edge, Mellieha Bay Hotel, Mellieha MLH 9065 - MALTA
Phone: (356) 21 522 141 / 21 522 356. Fax: (356) 21 521 053.
E-Mail: info@aquaventuremalta.com www.aquaventuremalta.com